Insurance for the business needing workers comp in Georgia

Application

Start the application process with the form below… We provide workers comp quotes once the online application is submitted. 

NOTE: WE NOW HAVE Pay-As-You-Go Workers Comp Insurance Solutions

 (low to zero down – pay only as you pay your employees)

Application-General Data
  3. (required)
  4. (valid email required)
  6. (required)
  11. (required)
Mulitiple Locations
Policy Info
Rating Information
  1. Workers Comp rates the policy based on the what the worker does. Breaking out each classs of worker ensures the proper rating on a per class basis. Example: Clarical Office Staff - 4 full time 2 part time payroll totaling x.xx.
Prior Carrier Loss History
Individuals to be included/excluded from coverage
  1. (required)
  2. (required)
  3. (required)
  4. (required)
  5. (required)
Nature of Businsess
General Informaiton
  1. 1.DOES APPLICANT OWN, OPERATE, LEASE AIRCRAFT/WATERCRAFT?

  3. 2. DO/HAVE PAST, PRESENT OR DISCONTINUED OPERATION INVOLVE(D) STORING, TREATING, DISCHARGING, APPLYING, DISPOSING, OR TRANSPORTING OF HAZARDOUS MATERIAL?#Yes

  6. 3. ANY WORK PERFORMED UNDERGROUND OR ABOVE 15 FEET?

  8. 4. ANY WORK PERFORMED ON BARGES, VESSELS, DOCKS, BRIDGE OVER WATER?

  10. 5. IS APPLICANT ENGAGED IN ANY OTHER TYPE OF BUSINESS?

  12. 6. ARE SUB-CONTRACTORS USED?

  14. 7. ANY WORK SUBLET WITHOUT CERTIFICATES OF INSURANCE?

  16. 8. IS A WRITTEN SAFETY PROGRAM IN OPERATION?

  18. 9. ANY GROUP TRANSPORTATION PROVIDED?

  20. 10. ANY EMPLOYEES UNDER 16 OR OVER 60 YEARS OF AGE?

  22. 11. ANY SEASONAL EMPLOYEES?

  24. 12. IS THERE ANY VOLUNTEER OR DONATED LABOR?

  26. 13. ANY EMPLOYEES WITH PHYSICAL HANDICAPS?

  28. 14. DO EMPLOYEES TRAVEL OUT OF STATE?

  30. 15. ARE ATHLETIC TEAMS SPONSORED?

  32. 16. ARE PHYSICALS REQUIRED AFTER OFFERS OF EMPLOYMENT ARE MADE?

  34. 17. ANY OTHER INSURANCE WITH THIS INSURER?

  36. 18. ANY PRIOR COVERAGE DECLINE/CANCELLED/NON-RENEWED (Last 3 years)?

  38. 19. ARE EMPLOYEE HEALTH PLANS PROVIDED?

  40. 20. IS THERE A LABOR INTERCHANGE WITH ANY OTHER BUSINESS/SUBSIDIARY?

  42. 21. DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS?

  44. 22. DO ANY EMPLOYEES PREDOMINANTLY WORK AT HOME?

  46. 23. ANY TAX LIENS OR BANKRUPTCY WITHIN THE LAST 5 YEARS?

  48. 24. ANY UNDISPUTED AND UNPAID WORKERS COMPENSATION PREMIUM DUE FROM YOU

Validation
 

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